In the Virsys12-IDC webinar, “Modernizing Provider Data Management Without Losing Your Mind or Your Provider Network,“, healthcare technology experts tackled one of the most challenging operational transformations facing healthcare organizations today. As a result, the discussion provided a comprehensive roadmap for overcoming the barriers that prevent organizations from moving beyond fragmented point tools toward integrated, end-to-end provider data management platforms. Drawing from extensive industry research and real-world implementation experience, the webinar offered systematic approaches to addressing the complex challenges that often make this critical transformation seem overwhelming to healthcare leaders.
Healthcare organizations worldwide are grappling with a critical transformation: moving from fragmented point tools to integrated, end-to-end provider data management platforms. While the benefits are clear, the barriers can seem overwhelming. Therefore, understanding these challenges and developing systematic approaches to overcome them is essential for organizations seeking to modernize their provider data operations.
Moderator Alaina Kilpatrick, Product Manager at Virsys12, set the tone: “This isn’t about buying one more tool. It’s about building a sustainable provider data foundation that will carry your organization through years of regulatory change and market disruption.”
The Holistic Assessment Imperative
The first and most critical step in platform transformation is taking a comprehensive inventory of the current state. To begin with, “Take an inventory of all the possible data sources of provider data in your organization,” advises Jeff Rivkin, Research Director of Payer IT Strategies at IDC. “Could be a bunch of spreadsheets and multiple targets, multiple sources out there that are used to put data into what you would put into a centralized repository.”
This assessment often reveals surprising complexity.
Data Sources Proliferation
Organizations typically discover provider data scattered across:
- Multiple departmental spreadsheets
- Legacy credentialing systems
- Contract management platforms
- Claims processing systems
- Provider portals and intake systems
- Email threads and document repositories
- Third-party verification services
Target System Complexity
“It’s not unusual to see a set of targets that are like 12 or more than a dozen,” notes Rivkin. In other words, these target systems often include provider directories, claims engines, reporting systems, regulatory submissions, and various departmental tools that all need accurate provider data.
Integration Challenges
Organizations frequently find “ETL jobs, web services, APIs…all moving data around,” he added. “It’s a complex web that’s hard to track and even harder to govern.”
Master Data Management Principles
Once organizations understand their current complexity, they need to apply rigorous master data management principles. Specifically, this involves asking fundamental questions about data ownership and lifecycle management:
“Who’s creating the provider data? Who is reading it? Who’s updating or deleting it? How’s it being archived?” explains Rivkin.
More importantly, organizations need “attribute-level ownership, not at the table level or at the record level.” This granular approach ensures clear accountability for provider data quality and consistency.
Architecture for Flexibility
The next challenge involves designing systems that can handle both current needs and future requirements. “You have little islands out there you need to integrate—multiple lines of business, mergers and acquisitions,” explains Rivkin.
To this end, this architectural approach requires:
- Plug-and-Play Design: able to connect a “bunch of different provider data sources and targets,” unify them, and scale seamlessly.
- Integration Flexibility: support APIs, microservices, ETL, and direct database connections as needed.
- Scalability: handle growing provider networks and expanding operational complexity.
Workflow Orchestration
Provider data architecture alone isn’t sufficient. Organizations must also address workflow management. Rivkin urged leaders to understand the verbs of provider data: “If the system of record are the nouns, then what are the verbs? How is workflow moving through the organization—for credentialing, contracting, directory management, onboarding?”
Key considerations:
- How approvals and reviews occur across departments
- Where external parties (providers, regulators, vendors) interact
- How automation can replace manual handoffs
The Document Challenge
Many organizations overlook the complexity of document management in their transformation efforts. “Talk about your documents, how are your documents flowing? What are their systems of truth? How are they being versioned and signed?” asks Rivkin.
For this reason, capturing and governing unstructured data—contracts, rosters, signed agreements—is essential to a truly integrated PDM platform.
API and Integration Strategy
With core systems and workflows addressed, organizations must consider how data will flow into and out of their platforms. “Consider how this provider data is going to get out and in—your APIs, microservices, containers. How flexible are they? Because change requirements will come fast.”
This flexibility is crucial because “How are you going to get your change requirements handled?” becomes a critical operational question as business needs evolve.
Provider Relationship Management
Platform transformation isn’t just an internal technology challenge—it affects provider relationships. “How are you going to educate your providers to the downstream value of having their data correct?” asks Rivkin.
This requires a balanced approach: “You want to keep your providers happy, you want to reduce abrasion, and you want to keep them in the network, but on the other hand, they’re not really into necessarily meeting all the standards you want to put on them.”
Organizations need “sort of a carrot and stick approach to how you manage provider relations” that considers both enforcement requirements and relationship preservation.
The Data Quality Reality
Perhaps the most sobering barrier organizations face is the reality of their current data quality. “Recognize that your provider data is probably very dirty, at a level of dirtiness that is going to be like 50 to 70% wrong,” warns Rivkin.
Accordingly, this reality means “you cannot leave your data alone, you have to keep it maintained. It is a big deal.”
From Annoying to Competitive Advantage
The transformation challenge is significant, but so is the opportunity. Indeed, “Now we’re moving from annoying to competitive advantage,” explains Rivkin. “A legitimate back office that enables seamless credentialing, contracting and directory management with continuously updated provider data lets you participate in interoperability and meet regulatory standards.”
Organizations that successfully transform their provider data management gain capabilities that directly support competitive positioning. In summary, benefits include:
- Regulatory Compliance: positive directory audits and protection from state penalties for inaccurate provider data.
- Operational Excellence: streamlined workflows and reduced manual effort.
- Strategic Agility: faster response to market opportunities and competitive pressures.
A Systematic Roadmap
Rivkin’s systematic approach provides a clear roadmap for organizations:
- Comprehensive Assessment: Inventory all provider data sources and targets
- Data Governance: Apply master data management principles with attribute-level ownership
- Architecture Design: Create plug-and-play systems that can handle complexity and growth
- Workflow Integration: Orchestrate processes across departments and external parties
- Document Strategy: Address both structured and unstructured data management
- API Planning: Design flexible integration capabilities for future growth
- Provider Relations: Balance enforcement with relationship management
- Data Quality: Commit to ongoing data maintenance and quality assurance
The Strategic Investment
Rivkin acknowledged that provider data clean-up and platform transformation aren’t glamorous, but they are unavoidable: “It’s not the most sexy thing to put on the PMO list,” he said, “but it’s critical if you want a competitive provider network.”
However, the competitive implications are clear. Organizations that invest in comprehensive provider data management platforms position themselves for success in an increasingly complex and demanding healthcare environment.
The barriers are significant, but they’re not insurmountable. Organizations that approach the transformation systematically, with clear understanding of the challenges and commitment to addressing them, can successfully move from fragmented point tools to integrated, competitive platforms that support their strategic objectives.
Ready to overcome the barriers and transform your provider data management from fragmented point tools to integrated competitive advantage? Contact us to learn how V12 Enterprise’s systematic approach can guide your organization through this critical transformation.
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